Customer Service Representative
Resume:
Theresa V. Johnson
*************@*****.***
PROFESSIONAL SUMMARY
Innovative, focused professional with more than 25 years of multi-industry experience in customer service along with 3 years of supervisory experience where I trained, supervised, and managed a team of 30 customer service representative daily while exceeding daily sale goals and quota while performing successfully in fast-paced call center environment. Asking for an opportunity so I can utilize and enhance my current skills so I can grow to my next level with your company.
SKILLS
Extensive customer service experience in healthcare insurance environment
Excellent interpersonal skills and an ability to recognize, understand, and respond to sensitive member issues or concerns
Ability to manage multiple priorities, have analytical and problem-solving skills. Outstanding time management skills
Strong critical thinking, object problem solving and prioritization skills. Focused on listening and performing first call resolution
Proven ability to work independently, as well as a team player, collaboratively and use appropriate judgement to make independent decisions by following guidelines
Strong organizational, analytical, and interpersonal skills with strong attention to detail
Profound knowledge of Medicare and Medicaid Eligibility, coverage and payment provisions
Advanced Knowledge of Medical Terminology and prescription drugs concepts
Experienced in billing, claims, finance, and collections
Proficient in Microsoft Office 365 and varies database platforms REMEDY, AS400, Lotus Notes, Direct Provider, ASD, PeopleSoft, Oracle, RHD, CSPRO, CMS, IEX, NICE, IRIS, Genesis, SharePoint, RXHD, Navigator, Quick Base, Script-med, DPASS, Knowledge Exchange, DentalQue, Webster, MHK, QNXT, ESD,
WORK HISTORY
Grievance and Appeals Coordinator, Cigna Virtual US
SpectraForce Technologies INC 09/2022-09/2023
Processed grievances and organization determinations, analyse, research, and provide comprehensive responses in accordance with established regulatory and accreditation guidelines
Contacted customers providers and vendors to gather information and communicate disposition of case
Conducted pertinent research in order to evaluate, respond to, and finalize case
Familiarized with standard concepts, practices, and procedures for analysing, interpreting data and applying contract and regulatory provisions
Analyzed, research, resolve and respond to confidential/sensitive complaints, grievances and organization determinations from members, member’s representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines
Make grievance decisions and communicate decision to the claimant within regulatory and accreditation guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws
Provided comprehensive grievances responses that support the decision and comply with regulatory and accreditation guidelines and support the decision by referencing specific and applicable language from the plan documents, certificates, riders, and summary plan descriptions, or the internal rules, guidelines and protocols, as appropriate
Theresa V. Johnson
*************@*****.***
Customer Service Advocate,
OPTUM, Virtual US 10/2017-08/2022
•Received incoming calls from members, providers, pharmacists or plan sponsors regarding prescription drug plan, benefits, paid claims, formulary/non formulary, deductibles, and copays. Explained rejected claims requiring prior authorization
•Created new patients’ profile along verified demographics added insurance information sent new prescriptions requests or prior authorization form to physician’s office, and setup payment method. Accurately documented information in appropriate platform
•Researched complex issues across multiple databases and work with support resources to resolve customer issues and/or partner with others to resolve escalated issues
•Ability to multi-task and understand plans and benefits and explain to member
•Adhered to all applicable internal and external policies and guidelines concerning member confidentiality and HIPAA regulations. Defused volatile customer situations professionally
•Submitted grievances and appeals and provided grievances and appeals resolutions
Patient Care Representative,
AETNA Specialty Pharmacy, Orlando, FL 08/2014–02/2017
•Effectively managed a high volume of inbound and outbound members calls. Defused volatile customer situations professionally calmly courteously
Provided telephone support to patients and physicians receiving life sustaining specialty drug therapy.
Responsible for the overall coordination and processing of new patient and existing patients Prescriptions orders and reorders
Created new patients’ profile, verified, and added insurance information along with demographics. Verified benefits Medicare, Commercial and copay information. Documented information in Remedy
•Adhered to all applicable internal and external policies and guidelines concerning member confidentiality and HIPAA regulations.
•Submitted grievances and appeals and provided grievances and appeals resolutions
Patient Care Advocate,
Accredo Specialty Pharmacy, Orlando, FL 06/2013–07/2014
Effectively managed a high volume of inbound and outbound members calls
Utilized active listening and communication skills to address customer inquiries and deescalated and escalated issue when necessary.
Documented interactions with customer to track requests, problems and resolutions
Provided telephone support to patients and physicians receiving life sustaining specialty drug therapy.
Responsible for the overall coordination and processing of new patient and existing patient’s prescriptions orders
Theresa V. Johnson
*************@*****.***
EDUCATION
A.A., General Studies Graduated 2018
Warner University, Lake Wales, FL
A.S., Business Administration and Management Graduated 2000
Lake Sumter Community College, Leesburg, FL
Financial Services/Marketing Certification Graduated 1995
Lake Vocational Technical Center, Eustis, FL
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